Keywords: D-Dimer (PubMed Search)
Causes of an Elevated D-Dimer
Don't forget the multiple causes of an elevated d-dimer:
**See attached PDF-Differential Diagnosis of Elevated D-Dimer
Journal of Thrombosis and Hemostasis, 2008
Keywords: electrocardiography (PubMed Search)
There are many causes of rightward axis on electrocardiography: RVH, COPD, acute (e.g. PE) or chronic (e.g. COPD, cor pulmonale) pulmonary hyptertension, sodium channel blocking drug toxicity (e.g. TCAs), ventricular tachycardia, hyperkalemia, dextrocardia, left posterior fascicular block, prior lateral MI, and of course misplaced leads.
In emergency medicine, however, the causes of acute/NEW rightward axis constitutes a smaller list. Perhaps the two most important causes of acute/new rightward axis in emergency medicine that should be remembered are PE and sodium channel blocker toxicity. In both of these conditions, the rightward axis may be the only obvious finding on the ECG.
The takeaway point is this: when you see new righward axis (compared to an old ECG) and you see nothing else "jumping out" at you, consider PE and consider sodium channel blocker toxicity.
Keywords: Femoral Vein, Access, Cannulation (PubMed Search)
Most people are now using Ultrasound to aid in cannulation of the femoral and internal jugular veins, but if you find yourself without the ultrasound machine you can increase your chance of successful cannulation of the femoral vein by positioning the leg properly.
Werner et al looked at the common femoral veins of 25 healthy volunteers and noted that the femoral vein was accessable more often when the hip was abducted and external rotated. This simple position change increased the mean diameter of the vein, and prevented the vein from being directly posterior to the artery.
Werner SL, Jones RA, Emerman CL. Effect of hip abduction and external rotation on femoral vein exposure for possible cannulation. J Emerg Med. 2008 Jul;35(1):73-5.
Keywords: Pyloric Stenosis (PubMed Search)
Keywords: mercury, poisoning (PubMed Search)
Keywords: neuropathy, knee injury, sural nerve, peroneal nerve, tibial nerve (PubMed Search)
-- IN SUMMARY:
*** Speaking of such deficits by naming the affected nerve distribution is particularly helpful when consulting orthopedists, neurologists, etc.
Category: Critical Care
Keywords: asthma, mechanical ventilation, hyperinflation (PubMed Search)
Mechanical Ventilation in Asthma
DeGiorgi A, White M. Ventilator management: maximizing outcomes in caring fo asthma, COPD, and pulmonary edema. Emergency Medicine Practice 2008;10(8):1-23.
Keywords: CT, Pulmonary (PubMed Search)
How good was that CT Pulmonary Angiogram You Ordered?
CT is currently the gold standard imaging modality for pulmonary embolism. Since we order these quite a bit in the ED, we should know some of the important nuances regarding interpretation of the scan. All of us at some point have looked at a pulmonary CTA and thought that it looked a bit "fuzzy" or perhaps it didn't "look right" This happens more often in obese patients. There is good literature to show that a suboptimal CTA misses clinically significant PE. So, it is important for emergency physicians to know a little about the CT scan ordered for our patients.
How can you know if the CT scan YOU ordered to rule out PE is really "good enough" to rule out PE?
So, a 34 yo obese patient who gets a CT scan to rule out PE, who has 170 HU in the main pulmonary artery, has not had an optimal CT. Thus, you really haven't ruled out PE even if the read is "negative." Often this is due to poor bolus timing.
American College of Radiology, Appropriateness Criteria, 2006
Keywords: Fracture, Management, Billing (PubMed Search)
In order to maximize billing when caring for patients with fractures two things should be done:
Finally, you should obtain post-reduction x-rays on any fracture that you manipulate and document that the patient is neurovascularly intact prior to discharge.
Keywords: reflux, esophagitis, misdiagnosis, myocardial infarction (PubMed Search)
The most common misdiagnosis in cases of missed acute MI is reflux esophagitis. Various studies have demonstrated the following factors that lead to this misdiagnosis:
1. 20% of patients with acute MI describe their pain using the words "indigestion" or "burning."
2. Almost 50% of patients with acute MI report an increase in belching during their ischemic symptoms.
3. 15% of patients get some relief of their ischemic pain with antacids and 7% of patients get complete relief of their ischemic pain with antacids.
4. 8% of patients report that their ischemic pain began while eating.
Before you ever write "Reflux esophagitis" or "GERD" on the chart of a patient you are about to send home, think twice about the possibility of acute cardiac ischemia.
Keywords: pediatric fever, pediatric seizure (PubMed Search)
PEDIATRIC FEVER + SEIZURE = FEVER
When a child has a fever and a seizure, do the age appropriate workup for a fever and you won't go wrong!!!
Keywords: Salicylate, aspirin, metabolic acidosisM (PubMed Search)
First Line Therapy: Urine Alkalinization (pH >7.5) by administrating NaHCO3
Other Indications for Hemodialysis in Salicylate Poisoned Patient:
Keywords: sciatica, sciatic nerve, foot drop (PubMed Search)
Category: Critical Care
Keywords: noninvasive ventilation (PubMed Search)
Noninvasive Ventilation Pearls
Garpestad E, Brennan J, Hill NS. Noninvasive ventilation for critical care. Chest 2007;132:711-20.
Keywords: Pulmonary Embolism, Pregnancy (PubMed Search)
Evaluating for Pulmonary Embolism During Pregnancy
Highest risk of PE is within the first week postpartum
Acceptable, safe, and medico-legally sound strategies to rule out PE in pregnancy:
**For explanation of PERC rule, see earlier pearl.
Kline J, Carolinas Medical Center, 2006-2008 published data
Keywords: myocarditis, pericarditis, myopericarditis (PubMed Search)
The pericardium is electrically silent, and so true acute pericarditis should not be associated with ECG changes. STE actually implies concurrent involvement of the myocardium; i.e. myopericarditis. The greater the degree of myocardium involved, the more ECG changes will develop, including STE, AV blocks, and dysrhythmias. Additionally, myocardial involvement is implied by elevated troponin levels, the magnitude of which is related to the amount of myocardial involvement.
[Imazio M, Trinchero R. Myopericarditis: etiology, management, and prognosis. Int J Cardiol 2008;127:17-26.]
Keywords: scaphoid, fracture (PubMed Search)
Keywords: Intussusception (PubMed Search)
Keywords: lactic acidosis, metformin, renal failure (PubMed Search)
Perrone et al. Occult metformin Toxicity in Three patients with profound lactic acidosis. J Emerg Med 2008, June 18.
Keywords: neurointerventionalist, vascular dissection, ischemic stroke, subarachnoid hemorrhage (PubMed Search)
Top Reasons to call your Neurointerventionalist: